Infective Syndromes of

Hepatobiliary System and

Abdomen
 Learning objectives

At the end of the session, the students will be able to understand:

▰ Infectious causes of Hepatitis

▰ Liver abscess

▰ Cholangitis and cholecystitis

▰ Infections of peritoneum and pancreas

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HEPATITIS
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HEPATITIS

▰ Hepatitis refers to inflammation of the liver.

▰ It can be self-limiting or can progress to fibrosis (scarring), cirrhosis or

hepatocellular cancer. The

▰ Causes of hepatitis - both infectious (more common) and noninfectious

such as toxic substances (e.g. alcohol, certain drugs), and autoimmune
diseases.
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HEPATITIS (Cont..)

▰ The various infectious causes of hepatitis include:

 Viral agents causing hepatitis

 Parasitic causes of hepatitis

 Bacterial hepatitis

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HEPATITIS (Cont..)

Viral agents causing hepatitis:

▰ Hepatitis viruses (HAV to HEV)

▰ Yellow fever virus

▰ Other viruses: Cytomegalovirus, Epstein-Barr virus, herpes simplex virus,

adenoviruses, rubella virus, hantaviruses, mumps virus and enteroviruses
such as Coxsackie viruses
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HEPATITIS (Cont..)
Parasitic causes of hepatitis:
▰ Echinococcus granulosus
▰ Trypanosoma cruzi and Leishmania species
▰ Entamoeba histolytica
▰ Fasciola hepatica
▰ Clonorchis sinensis
▰ Leishmania donovani, Schistosoma mansoni and S. japonicum—can cause
hepatomegaly
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HEPATITIS (Cont..)
Bacterial hepatitis:

▰ Bacterial agents associated with hepatitis - Leptospira interrogans,

Neisseria meningitidis, Neisseria gonorrhoeae, Bartonella henselae,
Borrelia burgdorferi, Salmonella species, Brucella species and
Campylobacter species

▰ Chronic or granulomatous hepatitis - Mycobacteria species, Tropheryma

whipplei, Treponema pallidum, Coxiella burnetii, and Rickettsia species.
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LIVER
ABSCESS
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Pyogenic Liver Abscess
▰ A pyogenic liver abscess - rare clinical condition characterized by single or
multiple collections of pus within the liver

▰ If left untreated, it can be fatal due to development of complications such

as peritonitis or sepsis.

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Pyogenic Liver Abscess (Cont..)
▰ Pathogenesis: Infection of liver - result from local spread from an adjacent
site within the peritoneal cavity - the biliary tract (most common source) or
ruptured appendicitis; or it may arise from hematogenous spread of the
organism from a distant site.

▰ In more than 50% of cases, it is cryptogenic (i.e., cause is unknown)

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Pyogenic Liver Abscess (Cont..)
▰ Manifestations: Fever and right upper quadrant tenderness - most
consistent clinical manifestations.

▰ Complications: Rupture of the liver abscess into adjacent organs or body

cavities - result into pleuropulmonary and intra-abdominal abscesses

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Pyogenic Liver Abscess (Cont..)
▰ Laboratory diagnosis: Blood culture is often positive.

▰ Culture of the liver aspirate obtained under CT guidance - useful

 Increased WBC count, elevated liver enzymes

 CT scan can be used to locate the abscess.

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Pyogenic Liver Abscess (Cont..)
▰ Treatment of liver abscess includes:

▰ Surgical drainage and administration of appropriate systemic antimicrobial

therapy, directed at the causative organism.

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Amoebic Liver Abscesses
▰ E. histolytica - spread from the large intestine to the liver by either
hematogenous route (more common) or direct contagious spread.

▰ Characterized by the presence of anchovy sauce pus in the liver

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INFECTIONS OF
THE BILE DUCT 17
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Cholangitis
▰ Refers to the inflammation of the bile duct.

▰ Infectious etiology of cholangitis may include bacteria or parasites or

viruses.

▰ Bacterial cholangitis occurs when a microorganism invades the biliary

tract and there is associated biliary obstruction (biliary stones) -
polymicrobial in nature. Bacteria that commonly cause cholangitis -
Escherichia coli, Klebsiella, Enterococcus,
Essentials Enterobacter, etc
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Cholangitis (Cont..)
▰ Biliary parasites cause necrosis, inflammation, fibrosis, strictures, and
cholangiectasis of the bile ducts.

▰ Common biliary parasites include:

 Trematodes - Opisthorchis, Clonorchis, and Fasciola hepatica,
Fasciola gigantica
 Cestodes - Echinococcus granulosus and
 Nematode - Ascaris
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Cholangitis (Cont..)
▰ Viral etiology of cholangitis may include hepatitis viruses and HIV.

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Cholecystitis
▰ Cholecystitis - inflammation of the gallbladder; characterized by symptoms
- right upper abdominal pain, nausea, vomiting, and occasionally fever.

▰ Presence of gallstone - blockade of bile flow – risk factor for the

gallbladder to become infected by bacteria, predominantly E. coli,
Klebsiella, Streptococcus, and Clostridium species; and viruses such
Epstein-Barr virus and HIV.
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OTHER INTRA-
ABDOMINAL
INFECTIONS
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Infection of the Peritoneum
▰ Intraperitoneal infections generally arise when the normal anatomic barrier
is disrupted.

▰ May result due to variety of causes - rupture of appendix or diverticulum,

weakening of the bowel wall (e.g. in inflammatory bowel disease) or with
adjacent organ infection (e.g. pancreatitis)

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Infection of the Peritoneum (Cont..)
▰ Following anatomical breach, the organisms from the bowel or adjacent
organ enter the normally sterile peritoneal space

▰ Intraperitoneal infections occur in two stages—peritonitis and abscess

formation in the peritoneum and the adjacent organs.

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Peritonitis
▰ Peritonitis (inflammation of the peritoneum) is of two types -

 Primary

 Secondary

▰ Both differ in their clinical presentations and etiological agents involved.

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Primary (Spontaneous) Bacterial Peritonitis

▰ Usually occurs in conjunction with cirrhosis of the liver or other

conditions.

▰ No apparent primary source of infection.

▰ Mostly caused by enteric gram-negative bacilli - E. coli.

▰ Gram-positive organisms - streptococci, enterococci, or pneumococci.

▰ Clinically presents with fever (most common), ascites, and abdominal pain.
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Secondary Bacterial Peritonitis
▰ Results from spillage of bacteria from an adjacent intra-abdominal viscus
such as intestine.

▰ The organisms implicated are mostly intestinal flora - enteric gram-

negative bacilli (e.g. E. coli) and anaerobes (e.g. Bacteroides fragilis).

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CAPD Peritonitis
▰ Peritonitis may also occur in patients who are undergoing continuous
ambulatory peritoneal dialysis (CAPD).

▰ Caused by endogenous bacteria.

▰ CAPD-peritonitis - involves skin organisms - Staphylococcus species.

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Peritoneal Abscess
▰ Peritonitis usually results in gram-negative sepsis; and is highly fatal.

▰ In some cases where overt sepsis either does not develop or develops but is
not fatal, it can progress further to develop peritoneal abscess.

▰ More commonly seen with Bacteroides fragilis infection

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Infection of Spleen
▰ Splenic Abscess

▰ Infectious Splenomegaly

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Infection of Pancreas (Pancreatitis)
▰ Majority of the pancreatitis are non-infectious.

▰ Gallstones and alcoholism - most common causative agents.

▰ About 10% of cases are thought to be caused by infectious

microorganisms, which include:

▰ Viruses—e.g. Mumps, Coxsackie viruses, echoviruses, cytomegalovirus,

Epstein-Barr virus, varicella-zoster virus, hepatitis viruses, HIV, measles,
and rubella virus Essentials of Medical Microbiology
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Infection of Pancreas (Pancreatitis)
(Cont..)

▰ Bacteria—e.g. Mycoplasma, Salmonella, Campylobacter and M.

tuberculosis

▰ Parasites—Ascaris can cause pancreatitis resulting from - migration of

worms in and out of the duodenal papillae. Other parasites include
Clonorchis species, P. falciparum, Fasciola hepatica, and hydatid disease

▰ Fungi—e.g. Aspergillus and Candida.

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Infection of Pancreas (Pancreatitis)
(Cont..)

▰ Clinical types: Acute pancreatitis may manifest as:

 Mild interstitial form (80% of cases) or

 More severe form (necrotizing pancreatitis), seen in 20% of cases.

 Pancreatic abscess - develop as a late complication of acute necrotizing

pancreatitis, occurring more than 4 weeks after the initial attack.

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Infection of Pancreas (Pancreatitis)
(Cont..)

▰ Major manifestations - abdominal pain (cardinal symptom), fever,

tachycardia, vomiting, sometimes with anorexia and diarrhea.

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Treatment of Pancreatitis
▰ Antibiotic - indicated only when bacterial infection is suspected (e.g.
abscess).

▰ Treatment - based on the culture report of FNAC guided pancreatic

specimen.

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Questions:
▰ Q1. Most common cause of splenic abscess is:

a. Streptococci

b. E. coli

c. Klebsiella

d. Pseudomonas

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Questions:
▰ Q2. Continuous ambulatory peritoneal dialysis peritonitis is more
frequently caused by:

a. Staphylococci

b. E. coli

c. Klebsiella

d. Pseudomonas
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